2004

C OPYRIGHT
2018 T HE AUTHORS . P UBLISHED BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED. A LL RIGHTS RESERVED.

A commentary by James G. Wright, CM,

MD, MPH, FRCSC, FRCS Ed, is linked to the
online version of this article at jbjs.org.

Outcomes of the Ponseti Method for Untreated

Clubfeet in Nepalese Patients Seen Between the
Ages of One and Five Years and Followed for at
Least 10 Years
Bibek Banskota, MRCS, MS, Prakash Yadav, MPH, Tarun Rajbhandari, MS, O.P. Shrestha, MS, Divya Talwar, MPH,
Ashok Banskota, MD, FRCS, and David A. Spiegel, MD

Investigation performed at the Hospital and Rehabilitation Center for Disabled Children, Banepa, Nepal

Background: To our knowledge, there are no reports of the Ponseti method initiated after walking age and with >10 years
of follow-up. Our goal was to report the clinical findings and patient-reported outcomes for children with a previously
untreated idiopathic clubfoot who were seen when they were between 1 and 5 years old, were treated with the Ponseti
method, and had a minimum follow-up of 10 years.
Methods: A retrospective review of medical records was supplemented by a follow-up evaluation of physical findings
(alignment and range of motion) and patient-reported outcomes using the Oxford Ankle Foot Questionnaire for Children
(OxAFQ-C). The initial treatment was graded as successful if a plantigrade foot was achieved without the need for an
extensive soft-tissue release and/or osseous procedure.
Results: We located 145 (91%) of 159 patients (220 clubfeet). The average age at treatment was 3 years (range, 1 to 5
years), and the average duration of follow-up was 11 years (range, 10 to 12 years). The initial scores according to the
systems of Pirani et al. and Diméglio et al. averaged 5 and 17, respectively, and an average of 8 casts were required.
Surgical treatment, most commonly a percutaneous Achilles tendon release (197 feet; 90%), was required in 96% of the
feet. A plantigrade foot was achieved in 95% of the feet. Complete relapse was rare (3%), although residual deformities
were common. Patient-reported outcomes were favorable.
Conclusions: A plantigrade foot was achieved in 95% of the feet initially and was maintained in most of the patients,
although residual deformities were common. Patient-reported outcomes were satisfactory, and longer-term follow-up with
age-appropriate outcome measures will be required to evaluate function in adulthood.
Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

T
he Ponseti method is minimally invasive, may be suc- associated with superior clinical outcomes compared with
cessfully performed by non-surgeons (enabling task extensive soft-tissue releases using a variety of outcome
shifting or sharing)1-3, is cost-effective4, and has been measures5-10.

Disclosure: This work was funded by a grant from the Global Health Center at the Children’s Hospital of Philadelphia. On the Disclosure of Potential
Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author
had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/F5).

Copyright
2018 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved. This is an open-access article
distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to
download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the
journal.

J Bone Joint Surg Am. 2018;100:2004-14 d http://dx.doi.org/10.2106/JBJS.18.00445

 2005
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S

Fig. 1
Summary of the treatment of 220 feet.

While numerous studies from both high and low-income mid-term5,6 to long-term7-10,12,13 follow-up studies available,
countries have documented successful results in 80% to and none, as far as we know, from a low-income country. A
90% of clubfeet treated during infancy5-11, there are very few substantial subset of patients from low-income countries

Fig. 2
Nineteen feet (9% of the 210 successfully treated with the Ponseti method) had evidence of equinovarus deformity at the time of follow-up assessment, with
7 feet (3%) classified as overt relapse (left), making initial contact with the lateral aspect of the midfoot or forefoot and not getting the heel down, and 12 feet
(6%) as residual deformities in that the patients had a heel strike and walked with the foot flat (right).
 2006
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S

Fig. 3-A Fig. 3-B

Figs. 3-A, 3-B, and 3-C The hindfoot was aligned in valgus in
47% (Fig. 3-A), neutral in 37% (Fig. 3-B), and varus in 17%
(Fig. 3-C).

Fig. 3-C
 2007
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
Fig. 4
Examples of residual forefoot adduction (22%) (left) and midfoot cavus (26%) (right).
are seen for treatment after walking age, and while positive
results have been reported at short-term follow-up1-3,14-24, to
our knowledge, no mid-term to long-term follow-up studies
are available.
The goal of this study was to evaluate the clinical findings
and patient-reported outcomes in children with a previously
untreated idiopathic clubfoot who were seen between the ages
of 1 and 5 years, were treated with the Ponseti method, and
were followed for a minimum of 10 years.
Materials and Methods
I nclusion criteria for this study were an untreated idiopathic
clubfoot in a child between the ages of 1 and 5 years who was
treated with the Ponseti method and had >10 years of follow-
up. Approval from the Nepal Health Research Council Ethical
Review Board was obtained. Serial casting with long leg plaster-
of-Paris casts was performed at 5 to 7-day intervals by physi-
otherapists; however, during the first 6 months of the program,
some of the casting was performed by the senior author
(D.A.S.) and orthopaedic surgical colleagues while transition-
ing this role to the physiotherapists. The tenotomies (percu-
taneous with a single cut) or other surgical interventions were
performed in the operating room by the attending staff or by
house officers under the supervision of attending staff. The foot
abduction orthosis was made in our workshop, and patients
were instructed to wear the orthosis at night until they were 5
years old; those treated after 5 years of age do not wear an
orthosis. Most of our patients are unable to receive outpatient
services because of a number of barriers, usually logistical and/
or financial challenges with weekly transportation to the hos-
pital, and they are accommodated in a rehabilitation ward until
completion of the initial phase of treatment.
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S
We performed a retrospective review of the medical
records, focusing on the initial treatment course and including
demographics (age and district), outpatient versus inpatient,
number of inpatient days, initial scores according to the sys-
tems of Pirani et al.25 and Diméglio et al.26, number of casts, and
whether a surgical procedure (and which procedure) was
required to achieve initial correction. The initial treatment was
graded as successful if a plantigrade foot was achieved with-
out the need for an extensive soft-tissue release and/or intra-
articular procedure and/or osseous procedure. A follow-up
evaluation of physical findings and patient-reported outcomes
was performed by a single examiner (P.Y.), and he traveled by
whatever means necessary to villages throughout the country
to evaluate patients who were unable to return to the hospital
but were located by our community-based rehabilitation
(CBR) staff. Data included (1) passive and active range of joint
motion in dorsiflexion and abduction measured in degrees
with a goniometer; (2) muscle strength (graded manually on a
scale of 1 to 5); (3) weight-bearing digital images of the foot
from the front, rear, and sides; (4) digital images of the patient
squatting; and (5) the Oxford Ankle Foot Questionnaire for
Children (OxAFQ-C) that was administered to each child or
adolescent27,28.
Hindfoot alignment was subjectively assessed by 3
reviewers on digital images (neutral, varus, or valgus) while the
presence of forefoot adduction (yes or no) and/or midfoot
cavus (yes or no) was noted in feet successfully treated with the
Ponseti method. In the absence of objective information on
alignment and mobility at the time when the last cast was
removed, other than the knowledge that the foot was planti-
grade, we chose to categorize residual abnormalities in align-
ment as (1) severe equinovarus, in which the heel strike is
 2008
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S

Fig. 5-A Fig. 5-B

Figs. 5-A, 5-B, and 5-C Modification of squatting to accommodate

loss of dorsiflexion. Fig. 5-A Although we are unaware of normative
data concerning range of motion required for normal squatting,
presumably full flexion at the hip and knee, and adequate dorsi-
flexion at the ankle, is required. Figs. 5-B and 5-C Patients with
residual equinus of 1 ankle (Fig. 5-B) or both (Fig. 5-C) modify their
squat by raising up on their metatarsal heads to shift their center of
gravity forward to avoid falling backward.

Fig. 5-C

TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
TABLE I Comparison of the Findings on the Child Version
of the OxAFQ-C in the Present Study and Those
6
in Duffy et al. *
Present
Child Scores Study† Duffy et al.†
from OxAFQ
Domains Ponseti Ponseti
Physical 86.0 ± 5.1 85.8 ± 12.8 96.8 ± 5.4
activity
School 98.9 ± 4.8 97.8 ± 7.5
and play
Emotional 95.4 ± 14.6 92.9 ± 9.8 99.8 ± 1.3
Footwear 84.5 ± 26.4 79.3 ± 32.8
*The findings in the present study compared favorably, with the
values approaching those of the control subjects. †The values are
given as the mean and the standard deviation.
absent and weight-bearing is on the dorsum or on the lateral
border of the midfoot and forefoot; (2) mild equinovarus in
patients who walked with their feet flat; and (3) other defor-
mities. Squatting was graded as normal if the patient was able to
position both feet flat on the ground and was able to balance
the trunk over the feet comfortably.
The OxAFQ-C is a patient-reported outcome measure
designed specifically to evaluate foot and ankle pathology in
patients from 5 to 16 years old27,28. Our first step was to per-
form a translation and a cross-cultural adaptation using a
focus group, which included orthopaedic surgeons, physio-
therapists, CBR staff, and several patients with their families.
The OxAFQ-C was filled out by the children or adolescents in
the presence of their parents and the administrator (P.Y.). The
questionnaire has 3 main domains: physical activity (6 items),
school and play (4 items), and emotional (4 items). In addi-
tion to these 14 items, the 15th item pertains to footwear
usage; however, this item scale is not specifically related to any
of the domains. The responses to each question are graded on
a 5-point Likert scale with 5 responses (never, rarely, some-
times, very often, and always).
Scoring of the OxAFQ-C was conducted using the
methodology of Morris et al.28. The data analysis was conducted
using IBM SPSS software (version 24.0; IBM). The data are
presented as the mean and the standard deviation as well as the
range for each domain.
The evaluator also asked patients and their parents
additional questions concerning their general satisfaction with
the treatment, current activities of daily living, level of confi-
dence, and educational level.
Results
W e were able to locate 145 (91%) of the 159 patients (220
of 234 clubfeet) meeting our inclusion criteria. During
the same time period, we treated 48 patients (66 feet) who were
<1 year old. The average age when treatment commenced was 3
years (range, 1 to 5 years), and the average follow-up was 11
2009
d
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S
years (range, 10 to 12 years). Seventy-five patients had bilateral
clubfoot, while 40 had involvement of the right side and 30 had
involvement of the left. Sixty-six percent of the patients were
male, and 91% were treated as inpatients, with an average
hospital stay of 46 days (range, 7 to 120 days). A small subset of
patients was admitted for 1 week, and they were then treated as
Control outpatients.
The pretreatment Pirani and Diméglio scores averaged 5
(range, 3.5 to 6) and 17 (range, 8 to 20), respectively. The initial
treatment with the Ponseti method was successful in achieving
100 ± 0
a plantigrade foot in 210 (95%) of 220 feet (Fig. 1), and an
average of 8 casts (range, 5 to 15 casts) were required, with 9
feet (4%) corrected with casting alone. Surgical procedures
99 ± 5 included a percutaneous tenotomy (197 feet) or open length-
ening (4 feet) of the Achilles tendon. The 10 failures required
either a posterior release (6 feet) or a posteromedial release (4
feet). Additional procedures included repeat percutaneous re-
lease of the Achilles tendon (9 feet), repeat open lengthening of
the Achilles tendon (3 feet), repeat posterior release (3 feet),
tibialis anterior tendon transfer (2 feet), talectomy (1 foot), and
osteotomy (1 foot). (A patient had >1 additional procedure.)
All 10 feet that failed the Ponseti treatment subsequently
needed additional surgical intervention, and at the latest
follow-up, 8 had a persistent severe equinovarus deformity.
Ninety percent of the patients claimed to have used the foot
abduction orthosis as recommended.
The 210 feet that were successfully treated by the
Ponseti method had an average active dorsiflexion of 5
(range, 25 to 15), with passive dorsiflexion of 11 (range,
220 to 20), active abduction of 15 (range, 210 to 30),
and passive abduction of 25 (range, 10 to 40). Alignment
at the time of follow-up is illustrated in Figure 1. Nine
percent (19 feet) had equinovarus; of those, 7 feet (3%) had
equinovarus with complete relapse and 12 (6%) had equino-
varus but the patients walked with the foot flat (Fig. 2). The
hindfoot was aligned in valgus in 98 feet (47%), in neutral in 77
feet (37%), and in varus in 35 feet (17%) (Figs. 3-A, 3-B, and 3-
C). The forefoot was mildly adducted in 46 feet (22%), while
residual cavus was identified in 54 feet (26%) (Fig. 4). Normal
squatting was possible for only 15% of the patients (all with
unilateral clubfoot), and 85% had a modified squat (Figs. 5-A, 5-
B, and 5-C).
Mean scores for each domain on the OxAFQ-C for all
145 patients included physical activity (86.0 ± 5.1; range, 58.3
to 100.0), school and play (98.9 ± 4.8; range, 75.0 to 100.0),
emotional (95.4 ± 14.6; range, 0 to 100.0), and footwear (84.5 ±
26.4; range, 0 to 100.0) (Table I). We examined the psycho-
metric properties of the survey instrument for internal con-
sistency (i.e., Cronbach alpha) and for construct validity (i.e.,
exploratory factor analysis). The reliability and validity of
OxAFQ-C constructs were good, with Cronbach alpha scores
ranging from 0.793 to 0.897. Detailed results will be published
separately.
On further questioning, 86% were completely satisfied,
with 96% having improved self-confidence and 99% having
improvements in activities of daily living. Ninety-six percent
 2010
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG d
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S

TABLE II Studies with Short-Term Follow-up of Patients Treated Beyond Walking Age* ä

Study Country No. of Feet Mean Age (Range) (yr) Provider Mean No. of Casts

Adegbehingbe et al.14 (2017) Nigeria 255 1 to >10 Orthop. surgeon 7

Ayana and Klungsøyr15 (2014) Ethiopia 32 4.4 (2-10) Orthop. surgeon 8

Spiegel et al.2 (2009) Nepal 260 2.4 (1-6) Physiotherapist or orthop. resident 7
Banskota et al.1 (2013) Nepal 55 7.4 (5-10) Physiotherapist or orthop. resident 9.5
Khan and Kumar19 (2010) India 25 8.9 (7-11) Orthop. surgeon 12
Sinha et al.22 (2016) India 41 3 (1-10) Orthop. surgeon 13
Verma et al.23 (2012) India 55 2 (1-3) Orthop. surgeon 10
Mehtani et al.21 (2018) India 62 3.1 (1-12) Orthop. surgeon 7
Faizan et al.17 (2015) India 28 2.7 (1-3.5) Orthop. surgeon 8
Lourenço and Morcuende20 (2007) Brazil 9 3.9 (1-9) Orthop. surgeon 5
Yagmurlu et al.24 (2011) Turkey 31 2 (1-6) Orthop. surgeon 6
Bashi et al.16 (2016) Iran 18 11.2 (6-19) Orthop. surgeon 9
Tindall et al.3 (2005) Malawi 100 25% were 18-48 mo Orthop. clinical officers 5

*Results are favorable. However, more casts are typically required, dorsiflexion is commonly mildly restricted, and the relapse rate has varied from 0% to 28%. †FAO = foot abduction orthosis, and
AFO = ankle-foot orthosis. ‡NR = not reported.

were able to complete household chores, while 92% partici- Discussion

pated in social activities, 94% played with their peers, and 94%
attended school. S tudies directly comparing the Ponseti method and exten-
sive soft-tissue releases have suggested that while the feet

TABLE III Reports on the Results of the Ponseti Method at Long-Term Follow-up* ä

Study Country or State No. of Feet Age Design

Cooper and Dietz12 (1995) Iowa 71 in patients and 97 in healthy <4 mo Retrospective
controls

Laaveg and Ponseti13 (1980) Iowa 104 <6 mo Retrospective

Ippolito et al.7 (2003) Italy 47 had surgery, and 49 had Ponseti <3 wk Retrospective
method

Smith et al.9 (2014) U.S. 24 in surgery group, 18 in Ponseti First wks Case controlled study
group, and 48 healthy controls

Church et al.5 (2012) U.S. 43 (surgery); 35 (Ponseti); 34 First wks Retrospective

(normal)

Sætersdal et al.8 (2012) Norway 134 (surgery) and 160 (Ponseti) First wks Ponseti versus surgery; multicenter

Švehlı́k et al.10 (2017) Austria 12 (surgery); 12 (Ponseti) <2 wk Randomized prospective

*Studies on the results of the Ponseti method at long-term follow-up, including some involving comparison with extensive soft-tissue releases, have demonstrated adequate clinical results;
however, relapses are relatively common, as are residual deformities. †FRS = Functional Rating Scale, DF = dorsiflexion, QOL = quality-of-life measures, AOFAS = American Orthopaedic Foot & Ankle
Society, ICFSC = International Clubfoot Study Group, PF = plantar flexion, PODCI = Pediatric Outcomes Data Collection Instrument, ASK = Activities Scale for Kids, and DSI = Clubfoot Disease Specific
Instrument.
 2011
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S

TABLE II (continued)

Orthosis† Mean Dorsiflexion‡ (Range) (deg) Initial Correction (%) Average Follow-up‡ Relapse‡ (%)

FAO NR 78 NR NR
FAO for those <4 yr old and AFO for NR 100 3 yr 13
those >4 yr old
FAO 12 (10-13) 94 NR NR
FAO 9 84 31.5 mo 16
Pronator shoes 7 (5-12) 86 4.7 yr 24
Steenbeek FAO 12 (3-20) 100 2.6 yr 17
FAO 12 (250 to 50) 89 30 mo 22
Steenbeek FAO 21 (10-45) 94 3 yr 10.6
FAO NR 93 2.7 yr NR
AFO · 12 mo 5 (0-10) 66 3.1 yr 28
FAO NR 100 42 mo NR
AFO · 3 mo NR 100 15 mo 0
FAO NR 98 NR NR

treated by both methods have reduced range of motion and
strength, and residual deformities are common in comparison
with normal feet, clubfeet treated with the Ponseti method
have better motion, greater strength, less pain, fewer degen-
erative changes on radiographs, fewer additional surgeries (of
lesser magnitude), and better outcomes in terms of function
and quality of life compared with feet treated with soft-tissue
releases5-10.
A plantigrade foot was achieved initially in 95% of the
feet in the present study, which is similar to rates achieved in

TABLE III (continued)

Mean Duration or Range

of Follow-up Mean Dorsiflexion Outcome Measure† Findings†

34 yr 6 in Ponseti group and
17 in control group
10-27 yr 13
25 yr for surgical group; 4 for surgical group
19 yr for Ponseti group and 9 for Ponseti
group
22 yr (surgery); 29 yr 5 (surgery); 3
(Ponseti); 23 yr (control) (Ponseti); 20 (control)
9 yr (surgical); 6 yr 2 (surgical); 10
(Ponseti) (Ponseti); 8 (normal)
8-11 yr 16 (surgery); 18
(Ponseti)
8-10 yr 12 (surgery); 14
(Ponseti)
Questionnaire, radiographs,
and pedobarographs
Questionnaire and
radiographs
FRS and radiographs
Physical examination,
radiographs, gait analysis,
QOL measures (AOFAS
scale and ICFSG scores)
Physical examination,
radiographs, gait analysis,
and QOL measures (PODCI,
ASK, and DSI)
FRS and DSI
FRS, ICFSG, and PODCI
78% excellent or good versus 85% for controls; hindfoot 5 varus to 8 valgus;
increased midfoot loading; results better if low-foot-demand occupation (92%
excellent or good versus 60%); outcome does not necessarily correlate with physical
examination or radiographs; residual deformities common but minimal degenerative
changes on radiographs
90% were satisfied; 47% had relapse, and 25% had second relapse; range of
motion limited; slightly under-corrected radiographically with 88% having lateral
wedging of navicular; moderate flattening of trochlear surface of talus; 24% had
occasional pain after strenuous activities and 9%, during routine activities
Surgical group had open heel cord and posterior release; FRS superior in Ponseti
group (78% versus 43% good to excellent); pain in 76% of surgical group versus
38% in Ponseti group; better DF and subtalar motion in Ponseti group; residual heel
varus and midfoot cavus in both groups; subtalar anatomy abnormal in both groups;
radiographic changes of osteoarthritis in 40% of surgical group and 20% of Ponseti
group; relapse in 47% of surgical group and 41% of Ponseti group
Both groups had reduced strength and motion compared with controls; Ponseti
group had greater plantar flexion motion and strength, less arthritis (3% versus 4%);
pain scores equal; both groups inferior to controls in physical function and QOL;
Ponseti group had better range of motion, greater strength, and less arthritis
Ponseti group had better range of motion (PF and DF) and greater push-off power
during ambulation; residual varus in both, more in surgical group; pedobarography
showed increased varus and decreased medial contact in surgical group;
radiographs showed increased equinus, cavus, and internal rotation in surgical
group; outcomes better following Ponseti on questionnaires.
Ponseti was superior in number and severity of surgical interventions, range of
motion, patient/parent reported outcomes (mainly because of less pain) with less
talar flattening on radiographs
Ponseti was superior in all 3 outcome measures and had less pain; feet in surgical
group needed twice the number of procedures and were stiffer.
 2012
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
patients treated during infancy. Studies concerning patients
treated beyond walking age have included 971 patients from
1 to 19 years old, and minor variations in the technique have
been incorporated (Table II)1-3,14-17,19-24. Five to 13 casts were
required, and most of the patients had a surgical intervention,
most commonly a percutaneous tenotomy or open lengthening
of the Achilles tendon. The initial correction rate was 66% to
100%, and relapse was observed in 0% to 28% at 1 to 5 years of
follow-up. The average passive ankle dorsiflexion ranged from
5 to 21. The Ponseti method must necessarily be adapted
when treating patients beyond walking age. For example, it is
difficult if not impossible to keep an ambulatory child in a
foot abduction orthosis full time for 3 months after the initial
correction is achieved, so immediate transition to nighttime
splinting is a reasonable alternative. Only 20 to 40 of passive
abduction may be achievable in older patients versus the 70
expected in infants. There has also been some variability in
how authors have chosen to address residual equinus, with
some favoring an open lengthening of the Achilles tendon
with or without a posterior release. Either a foot abduction
orthosis or an ankle-foot orthosis has been utilized to main-
tain correction.
We found that patient-reported outcomes were highly
favorable at an average follow-up of 11 years, and we chose the
OxAFQ-C as it is the only tool, to our knowledge, that focuses
on foot and ankle pathology in children. While there are both
parent and child versions of the questionnaire, all of our
patients were of sufficient age (>8 years old) for administering
the child version. The only other study using this tool in the
clubfoot population is by Duffy et al.6, who compared chil-
dren with normal feet and patients with a clubfoot treated
during infancy with either the Ponseti method or an extensive
soft-tissue release. They found that while both the patients
treated with the Ponseti method and those treated with an
extensive soft-tissue release had significantly lower scores
than the control group in all domains, those treated with the
Ponseti method had higher scores than the surgical group in
the “emotional” and “school and play” domains. These
findings were observed for both the child and parent versions
of the questionnaire, although it is unclear from the data
available whether there was any significant difference in a
comparison of scores between children and their parents. Our
findings were similar to those in the study by Duffy et al.,
indicating high degrees of function, considering that scores
approximating 100 would be expected in children without any
pathology involving the foot and ankle (Table I). Church
et al.5 utilized several quality-of-life measures, including the
Pediatric Outcomes Data Collection Instrument (PODCI),
the Activities Scale for Kids (ASK), and the Clubfoot Disease
Specific Instrument5, in patients at the 6-year follow-up after
treatment with the Ponseti method and found the scores to be
close to normal.
The few studies with a mean follow-up of >10 years
involved patients treated during infancy, used a variety of
outcome measures, and suggested that the functional results
were adequate despite the common presence of residual
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S
deformities (Table III)7,9,12,13. Cooper and Dietz12 found that
78% of their 45 patients had good to excellent results compared
with 85% of the age-matched controls at an average follow-up
of 34 years, and outcomes did not correlate with physical
findings or radiographic parameters. Residual deformities were
common but arthritic changes were not, and the results were
better when the patient’s occupation placed a low demand on
the feet. The mean dorsiflexion was 6 on bench examination
and 9 during ambulation12. Ippolito et al. modified the pro-
tocol of the Ponseti method by performing an open length-
ening of the Achilles tendon with a posterior capsular release7.
At the 19-year follow-up, they reported good to excellent
functional results in 78% of the feet managed with the Ponseti
method versus 43% of the feet treated with extensive soft-tissue
releases, with pain observed in 38% of the Ponseti group
versus 76% of those treated by extensive releases. Residual
deformities were common, especially midfoot cavus and heel
varus, and degenerative changes were observed in 40% of
surgically treated feet versus 20% of those treated with the
Ponseti method. The average dorsiflexion after treatment has
been reported to range from 3 to 187,9,12,13. The average
passive dorsiflexion in the group successfully treated with the
Ponseti method was 9, which is also within the range re-
ported in studies of patients of walking age (5 to 21)1,2,19-23.
While this did not seem to impact ambulation, most modified
their squat to accommodate loss of dorsiflexion (Figs. 5-A,
5-B, and 5-C).
Residual deformities and persistent morphologic ab-
normalities of the subtalar and transverse tarsal joints are
common when infants are treated with either the Ponseti
method or extensive surgical releases7,29-31. Ponseti et al.31
identified flattening of the talar head, misshapen subtalar
facets, and medial displacement of the hindfoot at 13 to 30
years of follow-up. We identified residual deformities in more
than one-third of the feet. This finding is not surprising given
the results reported for patients treated during infancy and
considering that remodeling of osteoarticular structures is
greatest during infancy and becomes less reliable as children
grow older. We cannot conclude whether these deformities
represent incomplete correction or relapse, or elements of
both, in the absence of objective data on alignment when the
final cast was removed and during the intervening period.
These residual deformities were usually mild and did not
appear to have any substantial impact on patient function or
satisfaction. Despite the residual deformities, we were surprised
that very few patients received additional treatment. It is
probable that a subset might have at least been offered ad-
ditional treatment had they been followed longitudinally.
Although follow-up services are available at the main hospital
and in the field through our CBR network, our experience
suggests that patients who are satisfied do not return for rou-
tine follow-up visits. Many patients refuse additional treatment
even if offered, and this was observed during data collection for
the present study. One might also hypothesize that our sur-
geons and/or patients may be more tolerant or accepting of
residual changes in foot alignment versus a matched cohort of
 2013
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
patients from Europe or North America. Nine percent of our
patients had persistent equinovarus deformity at the time of
follow-up, although only 3% of the total had complete relapse.
The lower than expected rates of clinically important relapse of
equinovarus may potentially relate to immediate weight-
bearing after cast removal and to the fact that motor control
and balance are more developed in this cohort than in those
treated during infancy.
There are several limitations to mention, including the lack
of a control group, a sizeable gap in time for most of our patients
between initial correction and latest follow-up, the inability to
verify the reported use of the orthosis, and the inability to ac-
curately characterize persistent changes in alignment as residual,
relapse, or a combination.
In conclusion, a plantigrade foot was achieved in 95% of
the idiopathic clubfeet in patients from 1 to 5 years old, and
most remained plantigrade and functioning well at an average
of 11 years of follow-up, with adequate patient satisfaction.
While residual deformities were common, and we could not
determine whether these were present after the initial treat-
ment phase or developed later, complete or overt relapse was
rare. Longer-term follow-up beyond the teenage years with
age-appropriate outcome measures will be required to eval-
uate function and patient satisfaction during adulthood. n
References
1. Banskota B, Banskota AK, Regmi R, Rajbhandary T, Shrestha OP, Spiegel DA.
The Ponseti method in the treatment of children with idiopathic clubfoot pre-
senting between five and ten years of age. Bone Joint J. 2013 Dec;95-B(12):
1721-5.
2. Spiegel DA, Shrestha OP, Sitoula P, Rajbhandary T, Bijukachhe B, Banskota
AK. Ponseti method for untreated idiopathic clubfeet in Nepalese patients from
1 to 6 years of age. Clin Orthop Relat Res. 2009 May;467(5):1164-70. Epub 2008
Nov 6.
3. Tindall AJ, Steinlechner CW, Lavy CB, Mannion S, Mkandawire N. Results of
manipulation of idiopathic clubfoot deformity in Malawi by orthopaedic clinical offi-
cers using the Ponseti method: a realistic alternative for the developing world? J
Pediatr Orthop. 2005 Sep-Oct;25(5):627-9.
4. Grimes CE, Holmer H, Maraka J, Ayana B, Hansen L, Lavy CBD. Cost-effective-
ness of club-foot treatment in low-income and middle-income countries by the Pon-
seti method. BMJ Glob Health. 2016 May 26;1(1):e000023.
5. Church C, Coplan JA, Poljak D, Thabet AM, Kowtharapu D, Lennon N, Marchesi
S, Henley J, Starr R, Mason D, Belthur MV, Herzenberg JE, Miller F. A compre-
hensive outcome comparison of surgical and Ponseti clubfoot treatments with
reference to pediatric norms. J Child Orthop. 2012 Mar;6(1):51-9. Epub 2012
Mar 6.
6. Duffy CM, Salazar JJ, Humphreys L, McDowell BC. Surgical versus Ponseti
approach for the management of CTEV: a comparative study. J Pediatr Orthop. 2013
Apr-May;33(3):326-32.
7. Ippolito E, Farsetti P, Caterini R, Tudisco C. Long-term comparative results in
patients with congenital clubfoot treated with two different protocols. J Bone Joint
Surg Am. 2003 Jul;85(7):1286-94.
8. Sætersdal C, Fevang JM, Fosse L, Engesæter LB. Good results with the Ponseti
method: a multicenter study of 162 clubfeet followed for 2-5 years. Acta Orthop.
2012 Jun;83(3):288-93. Epub 2012 May 23.
9. Smith PA, Kuo KN, Graf AN, Krzak J, Flanagan A, Hassani S, Caudill AK, Dietz FR,
Morcuende J, Harris GF. Long-term results of comprehensive clubfoot release versus
the Ponseti method: which is better? Clin Orthop Relat Res. 2014 Apr;472(4):
1281-90. Epub 2013 Nov 19.
10. Švehlı́k M, Floh U, Steinwender G, Sperl M, Novak M, Kraus T. Ponseti method is
superior to surgical treatment in clubfoot - Long-term, randomized, prospective trial.
Gait Posture. 2017 Oct;58:346-51. Epub 2017 Aug 11.
11. Jowett CR, Morcuende JA, Ramachandran M. Management of congenital talipes
equinovarus using the Ponseti method: a systematic review. J Bone Joint Surg Br.
2011 Sep;93(9):1160-4.
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S
NOTE: The authors thank Shyam Maharjan (Chief of Physiotherapy at the Hospital and Rehabilitation
Center for Disabled Children, Nepal) and all of our community-based rehabilitation workers for their
ongoing contributions and the Global Health Center at the Children’s Hospital of Philadelphia.
Bibek Banskota, MRCS, MS1
Prakash Yadav, MPH1
Tarun Rajbhandari, MS1
O.P. Shrestha, MS1
Divya Talwar, MPH2
Ashok Banskota, MD, FRCS1
David A. Spiegel, MD2
1Hospital and Rehabilitation Center for Disabled Children, Banepa, Nepal
2Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
E-mail address for D.A. Spiegel: spiegeld@email.chop.edu
ORCID iD for B. Banskota: 0000-0002-1628-1789
ORCID iD for P. Yadav: 0000-0003-0655-3151
ORCID iD for T. Rajbhandari: 0000-0003-1054-4530
ORCID iD for O.P. Shrestha: 0000-0003-2889-5937
ORCID iD for D. Talwar: 0000-0001-7995-8139
ORCID iD for A. Banskota: 0000-0002-5477-4541
ORCID iD for D.A. Spiegel: 0000-0001-6417-7735
12. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up
note. J Bone Joint Surg Am. 1995 Oct;77(10):1477-89.
13. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J
Bone Joint Surg Am. 1980 Jan;62(1):23-31.
14. Adegbehingbe OO, Adetiloye AJ, Adewole L, Ajodo DU, Bello N, Esan O,
Hoover AC, Ior J, Lasebikan O, Ojo O, Olasinde A, Songden D, Morcuende JA.
Ponseti method treatment of neglected idiopathic clubfoot: Preliminary
results of a multi-center study in Nigeria. World J Orthop. 2017 Aug 18;8(8):
624-30.
15. Ayana B, Klungsøyr PJ. Good results after Ponseti treatment for neglected
congenital clubfoot in Ethiopia. A prospective study of 22 children (32 feet)
from 2 to 10 years of age. Acta Orthop. 2014 Dec;85(6):641-5. Epub 2014
Sep 1.
16. Bashi RHZ, Baghdadi T, Shirazi MR, Abdi R, Aslani H. Modified Ponseti
method of treatment for correction of neglected clubfoot in older children and
adolescents—a preliminary report. J Pediatr Orthop B. 2016 Mar;25(2):
99-103.
17. Faizan M, Jilani LZ, Abbas M, Zahid M, Asif N. Management of
idiopathic clubfoot by Ponseti technique in children presenting after one
year of age. J Foot Ankle Surg. 2015 Sep-Oct;54(5):967-72. Epub 2014
Aug 12.
18. Johnson RR, Friedman JM, Becker AM, Spiegel DA. The Ponseti method for
clubfoot treatment in low and middle-income countries: a systematic review of
barriers and solutions to service delivery. J Pediatr Orthop. 2017 Mar;37(2):
e134-9.
19. Khan SA, Kumar A. Ponseti’s manipulation in neglected clubfoot in children
more than 7 years of age: a prospective evaluation of 25 feet with long-term follow-
up. J Pediatr Orthop B. 2010 Sep;19(5):385-9.
20. Lourenço AF, Morcuende JA. Correction of neglected idiopathic club foot by the
Ponseti method. J Bone Joint Surg Br. 2007 Mar;89(3):378-81.
21. Mehtani A, Prakash J, Vijay V, Kumar N, Sinha A. Modified Ponseti technique
for management of neglected clubfeet. J Pediatr Orthop B. 2018 Jan;27(1):
61-6.
22. Sinha A, Mehtani A, Sud A, Vijay V, Kumar N, Prakash J. Evaluation of
Ponseti method in neglected clubfoot. Indian J Orthop. 2016 Sep;50(5):
529-35.
23. Verma A, Mehtani A, Sural S, Maini L, Gautam VK, Basran SS, Arora S. Man-
agement of idiopathic clubfoot in toddlers by Ponseti’s method. J Pediatr Orthop B.
2012 Jan;21(1):79-84.
 2014
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 1 00-A N U M B E R 23 D E C E M B E R 5, 2 018
d d
24. Yagmurlu MF, Ermis MN, Akdeniz HE, Kesin E, Karakas ES. Ponseti manage-
ment of clubfoot after walking age. Pediatr Int. 2011 Feb;53(1):85-9.
25. Pirani S, Outerbridge H, Moran M, Sawatsky B. A method of evaluating the
virgin clubfoot with substantial inter-observer reliability. Presented at the Annual
Meeting of the Pediatric Orthopaedic Society of North America; 1995 Apr 29-May
4; Miami, FL.
26. Diméglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of
clubfoot. J Pediatr Orthop B. 1995;4(2):129-36.
27. Morris C, Doll H, Davies N, Wainwright A, Theologis T, Willett K,
Fitzpatrick R. The Oxford Ankle Foot Questionnaire for children: responsiveness
and longitudinal validity. Qual Life Res. 2009 Dec;18(10):1367-76. Epub 2009
Nov 3.
T H E P O N S E T I M E T H O D F O R C L U B F E E T I N N E PA L E S E P AT I E N T S W H O
W E R E F O L L O W E D F O R AT L E A S T 10 Y E A R S
28. Morris C, Doll HA, Wainwright A, Theologis T, Fitzpatrick R. The Oxford ankle foot
questionnaire for children: scaling, reliability and validity. J Bone Joint Surg Br. 2008
Nov;90(11):1451-6.
29. Farsetti P, De Maio F, Russolillo L, Ippolito E. CT study on the effect of different
treatment protocols for clubfoot pathology. Clin Orthop Relat Res. 2009 May;467(5):
1243-9. Epub 2009 Feb 4.
30. Ippolito E, Mancini F, Di Mario M, Farsetti P. A comparison of resultant subtalar
joint pathology with functional results in two groups of clubfoot patients treated with
two different protocols. J Pediatr Orthop B. 2005 Sep;14(5):358-61.
31. Ponseti IV, El-Khoury GY, Ippolito E, Weinstein SL. A radiographic study of
skeletal deformities in treated clubfeet. Clin Orthop Relat Res. 1981 Oct;(160):
30-42.